Assessment of prognostic factors in pediatric adrenocortical tumors: the modified pediatric S-GRAS score in an international multicenter cohort-a work from the ENSAT-PACT working group.

OBJECTIVE: Pediatric adrenocortical carcinoma (pACC) is rare, and prognostic stratification remains challenging. We aimed to confirm the prognostic value of the previously published pediatric scoring system (pS-GRAS) in an international multicenter cohort. DESIGN: Analysis of pS-GRAS items of pACC from 6 countries in collaboration of ENSAT-PACT, GPOH-MET, and IC-PACT. METHODS: We received patient data of the pS-GRAS items including survival information from 9 centers. PS-GRAS score was calculated as a sum of tumor stage (1 = 0; 2-3 = 1; 4 = 2 points), grade (Ki67 index: 0%-9% = 0; 10%-19% = 1; ≥20% = 2 points), resection status (R0 = 0; RX/R1/R2 = 1 point), age (<4 years = 0; ≥4 years = 1 point), and hormone production (androgen production = 0; glucocorticoid-/mixed-/no-hormone production = 1 point) generating 8 scores and 4 groups (1: 0-2, 2: 3-4, 3: 5, 4: 6-7). Primary endpoint was overall survival (OS). RESULTS: We included 268 patients with median age of 4 years. The analysis of the pS-GRAS score showed a significantly favorable prognosis in patients with a lower scoring compared to higher scoring groups (5-year OS: Group 1 98%; group 2 87% [hazard ratio {HR} of death 3.6, 95% CI of HR 1.6-8.2]; group 3 43% [HR of death 2.8, 95% CI 1.9-4.4]; group 4: OS 18% [HR of death 2.1, 95% CI 1.7-2.7]). In the multivariable analysis, age (HR of death 3.5, 95% CI 1.8-7.0), resection status (HR of death 5.5, 95% CI 2.7-11.1), tumor stage (HR of death 1.9, 95% CI of HR 1.2-3.0), and Ki67 index (HR of death 1.7, 95% CI 1.2-2.4) remained strong independent outcome predictors. Especially infants < 4 years showed more often low-risk constellations with a better OS for all tumor stages. CONCLUSION: In an international multicenter study, we confirmed that the pS-GRAS score is strongly associated with overall survival among patients with pACC. Age, resection status, stage, and Ki67 index are important parameters for risk stratification.

Impact of the uninstructed use of a herbal, ayurvedic toothpaste on parameters of gingival health in periodontal aftercare patients: A randomized, double-blinded, two-arm parallel-group study.

AIM: The aim of this study was to evaluate the impact of the uninstructed use of a toothpaste containing herbal ayurvedic ingredients on parameters of gingival health in a cohort of periodontal aftercare patients affected by gingival inflammation compared to the use of a standard, non-herbal toothpaste. MATERIALS AND METHODS: The monocentric, randomized, double-blinded, two-arm parallel-group intervention was performed in a cohort of 88 periodontal aftercare patients with clinical signs of gingival inflammation. At baseline, bleeding on probing (BoP), gingival index (GI) and Quigley-Hein plaque index (QHI) were recorded. Subsequently, the study patients were randomly provided with a herbal ayurvedic toothpaste (n = 44) or a conventional, non-ayurvedic control toothpaste (n = 44) and without additional oral hygiene training instructed to use it 2× daily for the next 28 days. On day 28, BoP, GI and QHI were recorded again. RESULTS: At baseline, there were no significant differences between both groups. On day 28, mean GI and BoP scores were significantly lower (p < 0.001) compared to baseline in both groups. Differences between the groups could not be verified. Mean QHI scores did not change significantly between day 0 and day 28 in both groups. CONCLUSIONS: The impact of uninstructed toothbrushing with an ayurvedic toothpaste on the manifestation of gingival inflammation in periodontal aftercare patients is not significantly different to the use of a conventional, non-herbal toothpaste.

Impact of Dietary Nitrate on the Recovery of Therapy-related Vascular Health Impairments Following Standard Periodontal Aftercare Therapy: a Hypothesis-generating Subanalysis.

This follow-up study assessed the impact of a nitrate-rich diet on salivary nitrate/nitrite levels and the recovery of therapy-induced vascular impairments in a cohort of 39 periodontitis patients treated by standard subgingival mechanical plaque removal (PMPR). At baseline, saliva samples for nitrate/nitrite analysis were collected, and peripheral/central blood and augmentation pressure was documented using the Arteriograph recording system. Immediately after, PMPR vascular parameters were reassessed. All study patients received a randomly allocated supply of a lettuce beverage to be consumed for 14 days, containing either a daily dosage of 200 mg nitrate (test group, n = 20) or being void of nitrate (placebo group, n = 19). At day 14, salivary and vascular parameters were reassessed. Initial salivary and vascular parameters did not differ significantly between the groups. PMPR impaired all vascular parameters in both groups with no differences between the groups. At day 14, salivary nitrate/nitrite levels of the test group were significantly elevated compared to baseline. All vascular parameters had significantly recovered from the impairment inflicted by PMPR. In the placebo group, by contrast, salivary parameters did not differ significantly from baseline, and the recovery of impaired vascular parameters was restricted to a significant improvement of diastolic blood pressure. Correlation analysis identified a significant inverse correlation between salivary nitrate/nitrite sum and central/peripheral blood pressure and augmentation pressure. In conclusion, the data of this subanalysis suggest that increasing salivary nitrate/nitrite levels by a diet rich in nitrate may improve recovery of therapy-induced vascular impairments after PMPR.

Intra- and Interrater Reliability of CT- versus MRI-Based Cochlear Duct Length Measurement in Pediatric Cochlear Implant Candidates and Its Impact on Personalized Electrode Array Selection.

BACKGROUND: Radiological high-resolution computed tomography-based evaluation of cochlear implant candidates' cochlear duct length (CDL) has become the method of choice for electrode array selection. The aim of the present study was to evaluate if MRI-based data match CT-based data and if this impacts on electrode array choice. METHODS: Participants were 39 children. CDL, length at two turns, diameters, and height of the cochlea were determined via CT and MRI by three raters using tablet-based otosurgical planning software. Personalized electrode array length, angular insertion depth (AID), intra- and interrater differences, and reliability were calculated. RESULTS: Mean intrarater difference of CT- versus MRI-based CDL was 0.528 ± 0.483 mm without significant differences. Individual length at two turns differed between 28.0 mm and 36.6 mm. Intrarater reliability between CT versus MRI measurements was high (intra-class correlation coefficient (ICC): 0.929-0.938). Selection of the optimal electrode array based on CT and MRI matched in 90.1% of cases. Mean AID was 629.5° based on the CT and 634.6° based on the MRI; this is not a significant difference. ICC of the mean interrater reliability was 0.887 for the CT-based evaluation and 0.82 for the MRI-based evaluation. CONCLUSION: MRI-based CDL measurement shows a low intrarater difference and a high interrater reliability and is therefore suitable for personalized electrode array selection.

Can cochlear implantation prevent cognitive decline in the long-term follow-up?

Cognitive function and hearing are known to both decline in older adults. As hearing loss is proposed to be one modifiable risk factor for dementia, the impact of auditory rehabilitation on cognitive decline has been gaining increasing attention. Despite a large number of studies, long-term data are still rare. In a large prospective longitudinal monocentric study, 50 adults (aged ≥ 50 years) with severe postlingual bilateral hearing loss received a cochlear implant (CI). They underwent comprehensive neurocognitive testing prior to implantation (T1), at 12 months (T2) and up to 65 months (T3) after implantation. Various cognitive subdomains such as attention, inhibition, working memory, verbal fluency, mental flexibility and (delayed) recall were assessed by the computer-based non-auditory test battery ALAcog©. The observed trajectories of two exemplary cognitive subdomains (delayed recall and working memory) were then fitted over time using multilevel growth models to adjust for sociodemographic covariates and compared with 5-year longitudinal data from a sample of older adults from the representative Survey of Health, Aging and Retirement in Europe (SHARE) study. Postoperatively, auditory functions improved from 6.98% (SD 12.83) to 57.29% (SD 20.18) in monosyllabic speech understanding. Cognitive functions significantly increased from T1 to T3 in attention (p = 0.001), delayed recall (p = 0.001), working memory (OSPAN; p = 0.001), verbal fluency (p = 0.004), and inhibition (p = 0.002). A closer look at follow-up revealed that cognitive improvement could be detected between T1 and T2 and thereafter remained stable in all subtests (p ≥ 0.06). Additional longitudinal analysis confirmed these findings in a rigorous multilevel approach in two exemplary cognitive subdomains. In contrast to the SHARE data, there was no evidence for age-differential associations over time in CI recipients. This suggests that older adults benefit equally from cochlear implantation. CI users with worse preoperative cognitive skills experienced the most benefit (p < 0.0001). Auditory rehabilitation by cochlear implantation has a stimulating effect on cognitive functions beyond an improvement in speech understanding and an increased well-being. Large multicenter studies using standardized protocols have to be undertaken in the future to find out whether hearing restoration might help to prevent cognitive decline.

Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registry.

BACKGROUND: Higher postoperative mortality has been observed among patients who received emergency colorectal surgery on the weekend compared to during the week. The aim of this study was to determine whether the weekday of emergency surgery affects the 30-day mortality and postoperative course in emergency colorectal surgery. METHODS: Prospectively acquired data from the 2010-2017 German StuDoQ|Colorectal surgery registries were analysed. Differences in 30-day mortality, transfer and length of stay (MTL30) (primary endpoints), postoperative complications, length of stay and pathological results of resected specimens (secondary endpoints) were assessed. Multivariable analysis was performed to identify independent risk factors for postoperative outcome. RESULTS: In total, 1,174 patients were included in the analysis. Major postoperative complications and the need for reoperation were observed more frequently for emergency colorectal surgery performed during the week compared to the weekend (23.01 vs. 15.28%, p = 0.036 and 17.96% vs. 11.11%, p = 0.040, respectively). In contrast, patients who received emergency surgery on the weekend presented with significantly higher UICC tumour stages (UICC III 44.06 vs. 34.15%, p = 0.020) compared to patients with emergency colorectal surgery on a weekday. Emergency surgery performed during the week was an independent risk factor for the development of severe postoperative complications (OR 1.69 [1.04-2.74], p = 0.033) and need for reoperation (OR 1.79 [1.02-3.05], p = 0.041) in the multivariable analysis. CONCLUSION: Emergency surgery for colorectal carcinoma in Germany is performed with equal postoperative MTL30 and mortality throughout the entire week. However, emergency surgery during the week seems to be associated with a higher rate of severe postoperative complications and reoperation.

Impact of a Specific Collagen Peptide Food Supplement on Periodontal Inflammation in Aftercare Patients-A Randomised Controlled Trial.

Background: This controlled clinical trial evaluated the impact of a specific collagen peptide food supplement on parameters of periodontal inflammation in aftercare patients. Methods: A total of 39 study patients were enrolled. At baseline, bleeding on probing (BoP; primary outcome), gingival index (GI), plaque control record (PCR), recession (REC) and probing pocket depth (PPD) for the calculation of the periodontal inflamed surface area (PISA) were documented. After subsequent professional mechanical plaque removal (PMPR), participants were randomly provided with a supply of sachets containing either a specific collagen peptide preparation (test group; n = 20) or a placebo (placebo group; n = 19) to be consumed dissolved in liquid once daily until reevaluation at day 90. Results: PMPR supplemented with the consumption of the specific collagen peptides resulted in a significantly lower mean percentage of persisting BoP-positive sites than PMPR plus placebo (test: 10.4% baseline vs. 3.0% reevaluation; placebo: 14.2% baseline vs. 9.4% reevaluation; effect size: 0.86). Mean PISA and GI values were also reduced compared to baseline, with a significant difference in favor of the test group (PISA test: 170.6 mm2 baseline vs. 53.7 mm2 reevaluation; PISA placebo: 229.4 mm2 baseline vs. 184.3 mm2 reevaluation; GI test: 0.5 baseline vs. 0.1 reevaluation; GI placebo: 0.4 baseline vs. 0.3 reevaluation). PCR was also significantly decreased in both experimental groups at revaluation, but the difference between the groups did not reach the level of significance. Conclusions: The supplementary intake of specific collagen peptides may further enhance the anti-inflammatory effect of PMPR in periodontal recall patients.

Assessment of prognostic factors in pediatric adrenocortical tumors: a systematic review and evaluation of a modified S-GRAS score.

Objective: Pediatric adrenocortical carcinoma (pACC) is rare and prognostic stratification remains challenging. We summarized the clinical prognostic factors of pACC and determined the prognostic value of the pediatric scoring system (pS-GRAS) in adaption to the recommendation (S-GRAS) of the European Network for the Study of Adrenal Tumors for the classification of adult ACC. Design: Analysis of pACC patients of 33 available retrospective studies in the literature. Methods: We searched the PubMed and Embase databases for manuscripts regarding pACC. The pS-GRAS score was calculated as a sum of tumor stage (1 = 0; 2-3 = 1; 4 = 2 points), grade (Ki67 index/rate of mitosis 0-9%/low = 0; 10-19%/intermediate = 1; ≥20%/high = 2 points), resection status (R0 = 0; RX = 1; R1 = 2; R2 = 3 points), age (<4 years = 0; ≥4 years = 1 point), hormone-related symptoms (androgen production = 0; glucocorticoid/mixed/no hormone production = 1 point) generating 10 scores and 4 groups (1: 0-2, 2: 3-4, 3: 5, 4: 6-9). The primary endpoint was overall survival (OS). Results: We included 733 patients. The median age was 2.5 years and >85% of pACC showed hormone activity (mixed 50%, androgen 29%, glucocorticoid 21%). Androgen production was associated with a superior OS. Increasing age correlated with higher rates of inactive or only glucocorticoid-producing tumors, advanced tumor stage, and case fatality. Especially infants < 4 years showed more often low-risk constellations with an increased OS for all tumor stages. The pS-GRAS score correlated with clinical outcome; median OS was 133 months (95% CI: 36-283) in group 1 (n = 49), 110 months (95% CI: 2.9-314) in group 2 (n = 57), 49 months (95% CI: 5.8-278) in group 3 (n = 18), and 16 months (95% CI: 2.4-267) in group 4; (n = 11) P < 0.05). Conclusion: The pS-GRAS score seems to have a high predictive value in the pACC patients, may serve as a helpful tool for risk stratification in future studies, and should be evaluated prospectively in an international context.

Influence of Matrix Type on Marginal Gap Formation of Deep Class II Bulk-Fill Composite Restorations.

Background: To test the hypothesis that transparent matrices result in more continuous margins of bulk-fill composite (BFC) restorations than metal matrices. Methods: Forty standardized MOD cavities in human molars with cervical margins in enamel and dentin were created and randomly assigned to four restorative treatment protocols: conventional nanohybrid composite (NANO) restoration (Tetric EvoCeram, Ivoclar Vivadent, Schaan, Liechtenstein) with a metal matrix (NANO-METAL) versus transparent matrix (NANO-TRANS), and bulk-fill composite restoration (Tetric EvoCeram Bulk Fill, Ivoclar Vivadent, Schaan, Liechtenstein) with a metal matrix (BFC-METAL) versus transparent matrix (BFC-TRANS). After artificial aging (2500 thermal cycles), marginal quality was evaluated by scanning electron microscopy using the replica technique. Statistical analyses were performed using the Mann−Whitney U-test and Wilcoxon test. The level of significance was p < 0.05. Results: Metal matrices yielded significantly (p = 0.0011) more continuous margins (46.211%) than transparent matrices (27.073%). Differences in continuous margins between NANO (34.482%) and BFC (38.802%) were not significant (p = 0.56). Matrix type did not influence marginal gap formation in BFC (p = 0.27) but did in NANO restorations (p = 0.001). Conclusion: Metal matrices positively influence the marginal quality of class II composite restorations, especially in deep cavity areas. The bulk-fill composite seems to be less sensitive to the influence of factors such as light polymerization and matrix type.

Poor Performer: A Distinct Entity in Cochlear Implant Users?

INTRODUCTION: Several factors are known to influence speech perception in cochlear implant (CI) users. To date, the underlying mechanisms have not yet been fully clarified. Although many CI users achieve a high level of speech perception, a small percentage of patients does not or only slightly benefit from the CI (poor performer, PP). In a previous study, PP showed significantly poorer results on nonauditory-based cognitive and linguistic tests than CI users with a very high level of speech understanding (star performer, SP). We now investigate if PP also differs from the CI user with an average performance (average performer, AP) in cognitive and linguistic performance. METHODS: Seventeen adult postlingually deafened CI users with speech perception scores in quiet of 55 (9.32) % (AP) on the German Freiburg monosyllabic speech test at 65 dB underwent neurocognitive (attention, working memory, short- and long-term memory, verbal fluency, inhibition) and linguistic testing (word retrieval, lexical decision, phonological input lexicon). The results were compared to the performance of 15 PP (speech perception score of 15 [11.80] %) and 19 SP (speech perception score of 80 [4.85] %). For statistical analysis, U-Test and discrimination analysis have been done. RESULTS: Significant differences between PP and AP were observed on linguistic tests, in Rapid Automatized Naming (RAN: p = 0.0026), lexical decision (LexDec: p = 0.026), phonological input lexicon (LEMO: p = 0.0085), and understanding of incomplete words (TRT: p = 0.0024). AP also had significantly better neurocognitive results than PP in the domains of attention (M3: p = 0.009) and working memory (OSPAN: p = 0.041; RST: p = 0.015) but not in delayed recall (delayed recall: p = 0.22), verbal fluency (verbal fluency: p = 0.084), and inhibition (Flanker: p = 0.35). In contrast, no differences were found hereby between AP and SP. Based on the TRT and the RAN, AP and PP could be separated in 100%. DISCUSSION: The results indicate that PP constitute a distinct entity of CI users that differs even in nonauditory abilities from CI users with an average speech perception, especially with regard to rapid word retrieval either due to reduced phonological abilities or limited storage. Further studies should investigate if improved word retrieval by increased phonological and semantic training results in better speech perception in these CI users.

Impact of a two-stage subgingival instrumentation scheme involving air polishing on attachment gain after active periodontal therapy.

BACKGROUND: The aim of this study was to evaluate whether clinical attachment level gain (ΔCAL) in deep untreated periodontal lesions may be improved by a two-stage, subgingival instrumentation scheme involving air polishing. METHODS: This 6-month, randomized, controlled, examiner-masked clinical trial was performed in 44 patients with periodontitis with untreated periodontal lesions ≥6 mm. At baseline, day 28, 84, and 168 CAL, probing depth (PD), bleeding on probing (BOP), and plaque control record (PlaCR) were recorded. After baseline examination control group patients received full-mouth sub- and supragingival instrumentation using scalers and curets. In the test group initial subgingival cleaning was limited to the removal of soft bacterial deposits by air polishing. Subgingival scaling and root planing was performed only after the first re-evaluation at day 28. RESULTS: In deep lesions ≥6 mm a significant reduction of mean CAL scores was observed at day 28 and at day 168 for both experimental groups. Differences between the groups however did not reach the level of significance. Mean PD was also significantly reduced at day 28 and at 168 in both experimental groups, with no significant differences between the groups. Mean BOP scores did not change significantly in both groups during the 168-day observation period. Only in the test group mean PlaCR scores were significantly reduced at day 168 compared with baseline. CONCLUSIONS: Subgingival instrumentation of untreated PD ≥6 mm by air polishing alone results in a significant short-term gain of CAL comparable to conventional scaling and root planing. Its sequential two-step combination with scaling and root planing, however, does not additionally enhance long-term gain of CAL.

Does allogeneic stem cell transplantation in survivors of pediatric leukemia impact regular physical activity, pulmonary function, and exercise capacity?

BACKGROUND: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has improved survival in high-risk childhood leukemia but is associated with long-term sequelae such as impaired pulmonary function and reduced exercise capacity impacting quality of life. METHODS: A convenience sample of 17 patients after allo-HSCT (HSCT-12 male, age 15.7±6.7 years, time after HSCT 5.3±2.8 years) underwent pulmonary function testing, echocardiography, and an incremental exercise test on a bike. Physical activity and health-related quality of life were assessed by questionnaires (7-day physical activity recall, PEDS-QL). Seventeen healthy age- and gender-matched controls served as control group (CG) for results of pulmonary function and exercise testing. RESULTS: HSCT showed reduced pulmonary function (HSCT vs. CG: FEV1 90.5±14.0 vs. 108.0±8.7%pred; FVC 88.4±19.3 vs. 107.6±6.9%pred, DLCO 75.3±23.6 vs. 104.9±12.8%pred) and exercise capacity (VO2peak 89±30.8%pred, CG 98±17.5%pred; Wmax 84±21.7%pred, CG 115±22.8%pred), but no relevant cardiac dysfunction and a good quality of life (PEDS-QL mean overall score 83.3±10.7). Differences in peak oxygen uptake between groups were mostly explained by 5 adolescent patients who underwent total body irradiation for conditioning. They showed significantly reduced diffusion capacity and reduced peak oxygen uptake. Patients reported a mean time of inactivity of 777±159min/day, moderate activity of 110±107 min/day, hard activity of 35±36 min/day, and very hard activity of 23±22 min/day. A higher amount of inactivity was associated with a lower peak oxygen uptake (correlation coefficient tau -0.48, p=0.023). CONCLUSIONS: This pilot study shows that although patients after allo-HSCT reported a good quality of life, regular physical activity and exercise capacity are reduced in survivors of stem cell transplantation, especially in adolescents who are treated with total body irradiation for conditioning. Factors hindering regular physical activity need to be identified and exercise counseling should be part of follow-up visits in these patients.

Adrenocortical Carcinoma in Childhood: A Systematic Review.

Adrenocortical tumors are rare in children. This systematic review summarizes the published evidence on pediatric adrenocortical carcinoma (ACC) to provide a basis for a better understanding of the disease, investigate new molecular biomarkers and therapeutic targets, and define which patients may benefit from a more aggressive therapeutic approach. We included 137 studies with 3680 ACC patients (~65% female) in our analysis. We found no randomized controlled trials, so this review mainly reflects retrospective data. Due to a specific mutation in the TP53 gene in ~80% of Brazilian patients, that cohort was analyzed separately from series from other countries. Hormone analysis was described in 2569 of the 2874 patients (89%). Most patients were diagnosed with localized disease, whereas 23% had metastasis at primary diagnosis. Only 72% of the patients achieved complete resection. In 334 children (23%), recurrent disease was reported: 81%-local recurrence, 19% (n = 65)-distant metastases at relapse. Patients < 4 years old had a different distribution of tumor stages and hormone activity and better overall survival (p < 0.001). Although therapeutic approaches are typically multimodal, no consensus is available on effective standard treatments for advanced ACC. Thus, knowledge regarding pediatric ACC is still scarce and international prospective studies are needed to implement standardized clinical stratifications and risk-adapted therapeutic strategies.

ESPED survey on newly diagnosed immune thrombocytopenia in childhood: how much treatment do we give?

BACKGROUND: Immune thrombocytopenia (ITP) is an autoimmune disease associated with isolated thrombocytopenia, which is caused by an imbalance between platelet production and platelet destruction. Petechial and mucous membrane hemorrhages are characteristic of ITP, but life-threatening bleeding rarely occurs. Depending on the bleeding symptoms, ITP can be treated with glucocorticoids (GC), intravenous immunoglobulins (IVIG), or in severe cases, platelet transfusions. Mild bleeding does not necessarily require therapy. Using the German Surveillance Unit for rare Pediatric Diseases (ESPED) we conducted a prospective survey on ITP patients in all German Children's Hospitals between September 2018 and August 2019. We collected data on ITP, including the clinical course, therapy implementation recommendations (according to the Association of German Scientific Medical Societies guidelines), outcome, and influence of treatment regimens depending on the treating physician´s experience with ITP patients. RESULTS: Of the 287 recorded cases of children with ITP, 268 questionnaires were sent to the authors. Two hundred seventeen of the questionnaires fulfilled the inclusion criteria. ITP affected boys and girls similarly, and the median age of manifestation was 3.5 years. The main reasons for hospitalization were thrombocytopenia, bleeding signs, hematomas, and/or petechiae. Bleeding scores were ≤ 3 in 96% of children, which corresponded to a low-to-moderately low risk of bleeding. No life-threatening bleeding was documented. The most common therapies were IVIG (n = 59), GC (n = 33), or a combination of these (n = 17). Blood products (i.e., red blood cells, platelet concentrate, and fresh frozen plasma) were given to 13 patients. Compared to the established guidelines, 67 patients were over-treated, and 2 patients were under-treated. CONCLUSIONS: Adherence to German ITP treatment guidelines is currently limited. To improve patient safety and medical care, better medical training and dissemination of the guidelines are required in line with targeted analyses of patients with serious bleeding events to identify potential risk constellations.

The utilization of dental emergency services during COVID-19 pandemic in a German university center: Do we lose vulnerable patients?

OBJECTIVES: The COVID-19 pandemic poses a major challenge to health care worldwide. As a part of the virus containment strategy, health care services were limited to the treatment of essential emergencies. The aim was to evaluate the influence of COVID-19 pandemic on patients' utilization of dental emergency services, focusing on patients vulnerable to severe courses of COVID-19. METHOD AND MATERIALS: Files of 1,299 patients of the Dental School of the University Hospital Wuerzburg between 3 February and 7 June 2020 were retrospectively analyzed. The observation period was divided into pre-lockdown (Pre-L), during lockdown (Dur-L), and post-lockdown (Post-L). Patients' demographics, diagnosis, and medical history including COVID-19 anamnesis were recorded. RESULTS: The number of dental emergency patients decreased by approximately 50% (Pre-L, n = 576; Dur-L, n = 309). Proportions of risk patients among them did not change. Stationary admissions increased by approximately 4% (Pre-L, 12.3% to Dur-L, 16.2%). The most frequent diagnosis was uncontrollable pain (45.6%), originating in 25.2% of endodontic and periodontal diseases. Abscesses (23.0%), dental trauma (16.5%), facial trauma (9.4%), and uncontrollable bleeding (5.5%) followed consecutively. CONCLUSION: Patients with an increased risk for severe courses of COVID-19 infection did not refrain from consulting dental emergency care. Dental emergencies should be treated early to avoid stationary admissions to preserve hospital bed capacities.

Impact of Cochlear Implantation on Neurocognitive Subdomains in Adult Cochlear Implant Recipients.

INTRODUCTION: Age-related hearing loss affects about one-third of the population worldwide. Studies suggest that hearing loss may be linked to cognitive decline and auditory rehabilitation may improve cognitive functions. So far, the data are limited, and the underlying mechanisms are not fully understood. The study aimed to analyze the impact of cochlear implantation on cognition in a large homogeneous population of hearing-impaired adults using a comprehensive non-auditory cognitive assessment with regard to normal-hearing (NH) subjects. MATERIAL AND METHODS: Seventy-one cochlear implant (CI) candidates with a postlingual, bilateral severe or profound hearing loss aged 66.3 years (standard deviation [SD] 9.2) and 105 NH subjects aged 65.96 years (SD 9.4) were enrolled. The computer-based neurocognitive tool applied included 11 subtests covering attention (M3), short- and long-term memory (recall and delayed recall), working memory (0- and 2-back, Operation Span [OSPAN] task), processing speed (Trail Making Test [TMT] A), mental flexibility (TMT B), inhibition (cFlanker and iFlanker), and verbal fluency. CI patients underwent a neurocognitive testing preoperatively as well as 12 months postoperatively. Impact of hearing status, age, gender, and education on cognitive subdomains was studied. Additionally, after controlling for education and age, cognitive performance of CI subjects (n = 41) was compared to that of NH (n = 34). RESULTS: CI users achieved significantly better neurocognitive scores 12 months after cochlear implantation than before in most subtests (M3, [delayed] recall, 2-back, OSPAN, iFlanker, and verbal fluency; all p < 0.05) except for the TMT A and B. A significant correlation could be found between the postoperative improvement in speech perception and in the attentional task M3 (p = 0.01). Hearing status (p = 0.0006) had the strongest effect on attention, whereas education had a high impact on recall (p = 0.002), OSPAN (p = 0.0004), and TMT A (p = 0.005) and B (p = 0.003). Inhibition was mainly age-dependent with better results in younger subjects (p = 0.016). Verbal fluency was predicted by gender as females outperformed men (p = 0.009). Even after controlling for age and education NH subjects showed a significantly better performance than CI candidates in the recall (p = 0.03) and delayed recall (p = 0.01) tasks. Postoperatively, there was no significant difference between the 2 groups anymore. CONCLUSION: Impact of cochlear implantation on neurocognitive functions differs according to the cognitive subdomains. Postoperatively, CI recipients performed as good as age- and education-matched NH subjects.

The Effect of Day of the Week on Morbidity and Mortality From Colorectal and Pancreatic Surgery.

BACKGROUND: A number of studies have revealed higher postoperative mortality after operations that were performed toward the end of the week. It is not yet known whether a day-of-the-week effect exists after visceral surgical procedures for cancer in Germany. METHODS: Data on resections of carcinomas of the colon, rectum (2010-2017), and head of the pancreas (2014-2017) (n = 19 703) that had been prospectively acquired by the Study, Documentation, and Quality Center of the German Society for General and Visceral Surgery were analyzed in relation to the day of the week on which the operation was performed. The primary endpoint was postoperative 30-day mortality; the secondary endpoints were complications, length of hospital stay, and MTL30 (a combined outcome criterion that is positive if the patient has died, is still in the hospital, or has been transferred to another acute care hospital 30 days after the index procedure). RESULTS: Resections of colon carcinomas that were performed on Mondays were associated with more advanced tumor stages (T4: 18.4% vs. 15.7%, p <0.001), higher 30-day mortality (3.5% vs. 2.3%, p = 0.004), and a more frequently positive MTL30 (10.5% vs. 8.5%, p = 0.004). Among patients who underwent pancreatic head resections, those whose procedures were on Tuesday had higher mortality (6.2% vs. 3.8%; p = 0.021). Among those who underwent surgery for rectal carcinoma, the day of the week on which the procedure was performed had no effect on postoperative morality. Multivariate analysis revealed that the independent risk factors for postoperative mortality were colonic resection on a Monday (odds ratio [OR]: 1.45; 95% confidence interval [1.11; 1.92], p = 0.008) and pancreatic head resection on a Tuesday (OR: 1.88 [1.18; 2.91], p = 0.006). CONCLUSION: Elective surgery for carcinoma of the colon or pancreatic head is associated with slightly higher mortality if per - formed toward the beginning of the week. On the other hand, the day of the week has no effect on the outcome of surgery for rectal carcinoma.

Benefits of Cochlear Implantation in Middle-Aged and Older Adults.

INTRODUCTION: Nowadays cochlear implantation (CI) is the treatment of choice in adults in case conventional hearing devices fail. Besides speech perception, an improvement in quality of life and in cognitive performance has been reported. Thereby, the study focused on the impact of age. PARTICIPANTS AND METHODS: Thirty middle-aged (MA) between 50 and 64 years and 41 older subjects (OA) aged 65 and older with bilateral severe hearing loss performed a comprehensive computer-based neurocognitive test battery (ALAcog) pre- and 12 months post-implantation. Besides, monosyllabic speech perception in quiet (Freiburg monosyllabic speech test), health-related quality of life (HR-QoL, Nijmegen Cochlear Implant Questionnaire) and depressive symptoms (GDS-15) have been assessed. RESULTS: Both age groups significantly improved in all three categories after 12 months. No differences were evaluated between MA and OA regarding speech perception and HR-QoL pre- and post-operatively. In contrast, cognitive performance differed between the age groups: pre-operatively OA performed worse in most neurocognitive subdomains like working memory (p=0.04), inhibition (p=0.004), processing speed (p=0.003) and mental flexibility (p=0.01), post-operatively MA outperformed OA only in inhibition (p=0.01). Age only slightly influenced cognitive performance in MA, whereas in OA age per se tremendously impacted on working memory (p=0.04), inhibition (p=0.02), memory (p=0.04) and mental flexibility (p=0.01). Educational level also affected processing speed, mental flexibility (p=0.01) and working memory (p=0.01). This was more pronounced in OA. In both age groups, hearing status had a strong effect on attentional tasks (p=0.01). In MA, depressive symptoms were more influential on cognitive functioning and on HR-QoL than in OA. Improvement in quality of life (p=0.0002) and working memory (p=0.001) was greater for those with a higher pre-operative depression score. CONCLUSION: Speech perception and HR-QoL improved in hearing impaired, independently of age. Pre-operative differences in cognitive performance between OA and MA clearly attenuated 12 months after CI. Impact of comorbidities differed between age groups.

Validation of MTL30 as a quality indicator for colorectal surgery.

BACKGROUND: Valid indicators are required to measure surgical quality. These ideally should be sensitive and selective while being easy to understand and adjust. We propose here the MTL30 quality indicator which takes into account 30-day mortality, transfer within 30 days, and a length of stay of 30 days as composite markers of an uneventful operative/postoperative course. METHODS: Patients documented in the StuDoQ|Colon and StuDoQ|Rectal carcinoma register of the German Society for General and Visceral Surgery (DGAV) were analyzed with regard to the effects of patient and tumor-related risk factors as well as postoperative complications on the MTL30. RESULTS: In univariate analysis, the MTL30 correlated significantly with patient and tumor-related risk factors such as ASA score (p<0.001), age (p<0.001), or UICC stage (p<0.001). There was a high sensitivity for the postoperative occurrence of complications such as re-operations (p<0.001) or subsequent bleeding (p<0.001), as well as a significant correlation with the CDC classification (p<0.001). In multivariate analysis, patient-related risk factors and postoperative complications significantly increased the odds ratio for a positive MTL30. A negative MTL30 showed a high specify for an uneventful operative and postoperative course. CONCLUSION: The MTL30 is a valid indicator of colorectal surgical quality.